‘Precarious (Bio)ethics: Research on Poisoning Patients in Sri Lanka’

On 9 May 2013, Salla Sariola, from ETHOX, gave a fascinating talk at the St Cross Ethics Seminar, based on work done collaboratively with Bob Simpson (Durham). The presentation focused on the large number of self-poisonings which have been taking place in Sri Lanka, often using lethal agricultural pesticides and herbicides unavailable in many developed countries. This presentation is now available as a podcast at the bottom right of the Oxford Uehiro Centre main webpage.

The rate of self-harm in Sri Lanka was the highest in the world in the 1990s, though there has been a large decrease in recent years, largely as a result of attempts to make pesticides less easily available. Many of these suicides have an interpersonal component, often involving a desire to ‘punish’ others for some perceived wrong, to express a loss of face, or to vent emotions such as a sense of frustration. The practice is so widespread that it has become normalized.

The problem has been recognized internationally, and there has been a certain amount of toxicological research on how self-harming patients are treated in Sri Lankan hospitals. Salla’s own work has been an ethnographic enquiry into the experience of those research subjects themselves, and her presentation includes a moving, first-hand description of the death of a 29-year-old who had taken a lethal dose of paraquat.

In general, self-harmers in Sri Lankan hospitals are stigmatized and mistreated in various ways, partly because their actions are seen as going against the Buddhist view that one should not take life (which resonates with other religions in the country, including Christianity and Islam), and they are seen as wasting precious medical resources. Their own failure to value their own lives is reflected in how they are valued by others, and Salla calls these patients ‘abjects’. Conditions in such hospitals, especially rural ones, are anyway poor, and self-harmers are at times tied to beds in an attempt to restrain them.

Self-harmers who volunteer to participate in research programmes, Salla argues, change status from ‘abject’ to ‘object’ or even ‘subject’. They are probably primarily motivated by a desire for better treatment, which they do indeed receive. They are more regularly monitored, and their treatment is regulated by international bioethical agreements. But they also benefit from greater respect, and this can even take them from the level of objecthood to ‘subjecthood’ (the position of an autonomous person whose rights are being respected).

This is where the precariousness of ethics comes in. On the one hand, the involvement of these patients in research is largely beneficial to them and the hope is that these ‘ob jects’ will become ‘subjects’, whose autonomy will be properly respected. On the other, there is a long history of exploitative experimentation on the vulnerable. At present, the rights of this group of vulnerable patients are being better protected; but there is always a risk, in the particular and the general case, of a change for the morally worse. Alertness and monitoring of the situation are essential safeguards.

This was a highly suggestive and multifaceted presentation, showing among other things how anthropological categories can assist bioethical thinking, how the status and risks of research subjects depend on context, and how sensitive researchers and doctors must be to that overall context.

A lively question-period followed. Topics pursued included the nature of stigmatization, the possible effects on consent of knowledge that one would receive better treatment if one volunteered, the progress on pesticide control and the role of multinational chemical companies, and the criteria for abjecthood, objecthood, and subjecthood.